Women Are Dying as Alabama Refuses to Expand Medicaid


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The Covid-19 crisis is pointing a spotlight on Alabama’s failure to expand Medicaid—a policy decision that has contributed to cervical cancer mortality rates that are unnecessarily killing poor women in astonishing numbers, The New Yorker reports.

Consequences of Alabama’s Opposition to Obamacare

Alabama is one of only 14 states that have not adopted the Medicaid expansion under the Affordable Care Act. In 2014, then-governor Robert Bentley rejected the expansion, arguing it would burden taxpayers and encourage “dependency on government,” Eyal Press wrote for The New Yorker.

The consequences of Alabama’s refusal to expand Medicaid have been devastating. It has contributed to the closure of 14 hospitals since 2010, more than half in rural areas.

While states that expanded Medicaid saved the lives of more than 19,000 adults between the ages of 55 and 64 alone from 2014 to 2017, the National Bureau of Economic Research found that 15,500 lives were lost in the states that rejected expansion.

And at least one study found that, contrary to arguments that expansion would be too costly for taxpayers, Alabama has lost out on a $935 million net surplus that expanding Medicaid would have generated.

Today, an Alabama parent in a family of four qualifies for Medicaid benefits only if their household income is less than $393 a month (about 18% of the poverty line). Only Texas has more stringent income requirements. Expanding Medicaid would provide coverage for roughly 340,000 Alabamians—about half of whom would be low-income white people.

A Deadly but Preventable Epidemic

Thanks to the widespread use of Pap smears and a vaccine for the human papillomavirus (HPV), cervical cancer has dropped from its top spot as the deadliest cancer among American women. The New Yorker reports that most physicians now view cervical cancer as preventable—especially for affluent women. But more than 4,000 women will die from cervical cancer this year in the U.S., mostly in the poorer parts of less wealthy states.

Women who develop cervical cancer in Alabama are more likely to die than in any other state—and Alabama’s mortality rate is rising.

Researchers say the loss of doctors and medical facilities in small towns and rural areas in Alabama contributes to the proliferation of cervical cancer, which disproportionately affects poor women and women of color. Due to Alabama’s refusal to expand Medicaid, rural hospitals cut essential services, causing the number of rural counties with hospitals that provide obstetric services to fall from 45 in 1980 to just 16 in 2019.

The lack of pediatricians (there are none in 24 of Alabama’s 67 counties) and absence of state-mandated sex education means the state’s HPV-vaccination rates are low. And a 2018 report found that Alabama women without health insurance often didn’t get medical care until their cancers were already in advanced stages.

Last year, a coalition of medical specialists, administrators, and survivors appointed by the Alabama legislature and the state’s governor reported that Alabama has the third highest ovarian cancer mortality rate in the country, even though cases of ovarian cancer are slightly less common in the state than in the U.S. as a whole. “Cervical cancer is almost entirely preventable,” it stated, “and yet in Alabama there are areas where women are dying at a rate similar to that of developing nations.”

A Legacy of Racial Injustice

Alabama’s refusal to expand Medicaid has hit especially hard in its poorest counties—the rural counties in the state’s Black Belt region, where residents have suffered for decades from the disastrous public health consequences of inadequate wastewater treatment and environmental racism.

Researchers examining Alabama’s Black Belt found that Black women in Alabama are almost twice as likely as white women to die if they develop cervical cancer.

Racial discrimination in the health care system is a legacy of our history of racial injustice. The “Father of Gynecology” was a white doctor in Montgomery, Alabama, who performed painful experiments without anesthesia on enslaved Black women in the 1840s.

Today, in the very same region where Black women suffered unspeakable horrors that led to medical breakthroughs for white women, researchers found that “even when Black women with cervical cancer earn as much as white women, they are still at higher risk of death from the disease.”

Alabama also has one of the highest maternal mortality rates in the country. As Jennifer Pierce, a gynecologic oncologist in Mobile, told The New Yorker, “It is more lethal to be Black and pregnant in Alabama than in some poor countries.”